Junior Fillies Volleyball Registration

Participant's Name*

PrefixFirst NameLast Name

Participant's Age

Grade (2018-2019 school year)

Shirt Size*

Parent/Guardian's Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Area CodePhone Number

E-mail*

Please list allergies, medications, health problems, or any other special considerations:

If none, please list "none or N/A"

Preferred Physician

Phone Number

Area CodePhone Number

Emergency Contact*

Phone Number*

Area CodePhone Number

Insurance Company

Policy #

In the event of a medical emergency, I authorize the personnel of Panola College to seek appropriate medical attention on my behalf. (please initial)*

RELEASE & WAIVER OF LIABILITY: The undersigned hereby acknowledges that participation in this league and related activities involves a possible risk of physical injury. The undersigned, hereby assumes all such risk and does hereby release and forever discharge Panola College and all the employees and agents thereof from any and all liability of whatever kind or nature, rising from and by reason of any and all known and unknown, foreseen and unforeseen, bodily injury and personal injuries, damage to property, and the consequences thereof, resulting from the registrants participation in or involvement with this league, including any failure of equipment or defect in the premises. I hereby state that I agree and acknowledge.

I have read and understood the liability policy stated above. (please initial)*

MEDIA RELEASE: I hereby authorize Panola College to photography me in still picture and motion picture form, and to record my voice, or to cause such photographs and pictures and recording to be made. I hereby consent to the exhibition of such photographs and pictures and the use of my name and voice by you, the world, whether such exhibition and use are sponsored or not. I also consent to the use of such photographs, the right to use my name, voice and photographs and pictures in advertising and in publicity in connection with a subsequent exhibition, and in the exhibition itself. I hereby release you and all other parties from any and all liability, claims or causes of action, arising out of, or created by, the use of my photograph or photographs, picture or pictures, and name and voice, as set forth above. This authorization, consent and release shall apply to all photographs, pictures and recordings of the above-signed, made with the knowledge and acquiescence of the above-signed, from the date hereof until the above-signed shall give you written notice that this authorization, consent and release in no longer effective. This agreement shall be binding on me, my heirs, administrators and executors, and shall inure to the benefit of you, your successors, assigns or licensees.

I have read and understood the media release policy stated above. (please initial)*

Payment*

Junior Fillies Registration Fee$50.00

Total $0.00

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